Jean Watson

Angeles University Foundation Graduate School

Angeles City

ERNESTINE WIEDENBACH’S

HELPING ART OF CLINICAL NURSING

And

JEAN WATSON’S

THEORY OF HUMAN CARING

In partial fulfillment of the requirements in Theoretical Foundations in Nursing

Submitted by:Rosella Marie M. Ocampo, R.N.

Submitted to:Mary Grace D. Brackett, R.N., Ph. D.

Theoretical Foundations in Nursing Professor

March 19, 2011

ERNESTINE WIEDENBACH’S HELPING ART OF CLINICAL

NURSING

I. INTRODUCTION

"My thesis is that nursing art is not comprised of rational nor reactionary

actions but rather of deliberative action."

Wiedenbach, 1964

Nursing encompasses autonomous and collaborative care of

individuals of all ages, families, groups and communities, sick or well and in

all settings. Nursing includes the promotion of health, prevention of illness,

and the care of ill, disabled and dying people. Advocacy, promotion of a safe

environment, research, participation in shaping health policy and in patient

and health systems management, and education are also key nursing roles.

As Wiedenbach quoted, nursing is a deliberative (responsible action). It

is not the result of an instinct but a result of the nurse’s purpose to help and

individual in need. Nursing is both patient and nurse centered which means

that it is mutual. More and more people are in need of help and it has been

an imperative for nurses to care the people who are in need of help. Helping

behavior refers to voluntary actions intended to help the others, with reward

regarded or disregarded. It is a type of prosocial behavior (voluntary action

intended to help or benefit another individual or group of individuals, such as

sharing, comforting, rescuing and helping).

Persons are different from each and it is a challenge for nurses to

develop an individualized nursing care plan. Wiedenbach’s theory is a

solution to the obstacle faced by nurses. It is within this theory that there is a

mutual understanding between the nurse and the patient being cared for

gearing toward the goal of meeting the needs of the patient.

OBJECTIVES:

Upon successful completion of this discussion, the reader will be able to:

Describe the historical background of the development of

Wiedenbach’s model for health

Define Wiedenbach’s Prescriptive theory and Helping Art of Clinical

Nursing

Present the relationship between Wiedenbach’s model and concepts in

nursing’s metaparadigm

Provide an example of use of Wiedenbach’s model in clinical practice

II. THEORY ANALYSIS

HISTORICAL EVOLUTION OF THE THEORY/ BACKGROUND OF THE

THEORIST

Ernestine Wiedenbach was born on August 18, 1900, in Hamburg, Germany

to an American mother and a German father who migrated to the United

States when Ernestine was a child. The affluent family supported the idea of

a college education for their daughter and she graduated with a Bachelor of

Arts degree from Wellesley College in 1922. Her later interest in a nursing

career was reluctantly accepted by her family. Pursuing nursing in this era

was atypical for someone who came from a family of gentility (Parker, 2001).

Her independent characteristics overruled her parents’ reluctance and

enrolled in a hospital school of nursing. Early in her studies there, her

advocacy for quality nursing education and her leadership role with her

classmates resulted in dismissal from the school. Through the intervention of

friends and faculty, including that of Adelaide Nutting, who realized her

potential, she was admitted to Johns Hopkins School of Nursing and

graduated in 1925 (Nickel, Gesse, & MacLaren, 1992.) (Parker, 2001).

Wiedenbach had many interests and held a variety of professional

positions. Because of her interest in education, she began taking graduate

courses part time at Columbia University. She was also involved with the

New York State Nurses’ Association and with various nuring committees.

After completing a master of arts in 1934, she became a professional writer

for the American Journal of Nursing (AJN) (Parker, 2001).

This position brought new opportunities to experience many different

facets of nursing and to meet national leaders in both nursing and health

care. Her tenure in the AJN office included the years during World War II,

when she played a critical role in the recruitment of nursing students and

military nurses (Parker, 2001).

After the war, she returned to clinical practice and to her love of

maternal-child nursing. At age 45, she began her studies in nurse-midwifery.

At the Maternity Center in New York City, her personal mentors included

such pioneers such ad Hazel Corbin and Hattie Hemschemeyer (Parker,

2001).

In 1952, Wiedenbach joined the faculty of Yale University School of

Nursing where her roles as practitioner, teacher, author, and theorist would

be consolidated. She retired from Yale in 1966 as an associate professor

emeritus and subsequently held part-time positions at California State

University and the University of Florida. She eventually moved to a Miami,

Florida, retirement village with her college roommate and lifelong friend,

Caroline Falls (Parker, 2001).

In 1972, Marcia Dombro, who was active in Miami’s childbirth

education movement, heard that Wiedenbach is living nearby. She

telephoned and requested Wiedenbach’s participation in a childbirth

education conference being held at Florida International University (FIU).

Wiedenbach graciously accepted and invented Dombro to her house for tea

to discuss it further (Parker, 2001).

Following this contact and the childbirth education conference,

Wiedenbach and Falls became involved in developing and teaching a

university course on communication in nursing. Her pattern of intellectual

productivity continued with the publication of another book: Communication:

Key to Effective NursingI (Wiedenbach & Falls, 1978) (Parker, 2001).

Wiedenbach’s love for interaction with students persisted even after

her mobility decreased. She and Caroline Falls continued to give informal

seminars in their home for Professor Theresa Geese and the University of

Miami nurse-midwifery students. They enjoyed discussing the past, present,

and future of nursing and nurse-midwifery and she always reminded

students and faculty of the need for clarity of purpose, based on reality

(Parker, 2001).

This rekindling of ties to the nursing education community did not

deter Wiedenbach from being an advocate for the residents of the retirement

village. She was an activist in promoting change in policies and practices

related to nutrition and creative activities for many talented residents now in

their late stages of life. She was adamant about improvement of the quality

of life and level of independence for those who lived in the village, where she

continued to apply her perspective theory of nursing in everyday living. She

even continued to use her gift for writing to transcribe books for the blind,

including Lamaze childbirth manual, which she prepared on her Braille

typewriter. Wiedenbach continued to be productive and maintain a central

purpose as long as she was able (Parker, 2001).

In 1992, events began to occur that profoundly affected Wiedenbach’s

remaining years. During this period, her friend Caroline Falls died of heart

failure, and Hurricane Andrew destroyed the retirement village, causing a

temporary relocation into unfamiliar surroundings. Susan Nickel, who had

become a personal friend, searched for Wiedenbach was much in need of the

caring that she herself had promoted so strongly in nursing. Wiedenbach

stayed at Ms. Nickel’s home for several months until the retirement village

was restored (Parker, 2001).

Until the end of her life, Wiedenbach continued to maintain the

independent spirit that originality fueled her productivity and creativity. In

April 1998, Wiedenbach died at age 98 (Parker, 2001).

APPROACH TO THE DEVELOPMENT OF THE MODEL

WIEDENBACH’S THEORY AND NURSING’S METAPARADIGM

Wiedenbach (1964) emphasizes that the human or individual possesses

unique potential, strives toward self-direction, and needs stimulation.

Whatever the individual does represents his or her best judgment at the

moment. Self-awareness and self-acceptance are essential to the individual’s

sense of integrity and self-worth. Wiedenbach believes these characteristics

require respect from the nurse (George, 2008).

Wiedenbach (1977) does not define the concept of health. However,

she supports the World Health Orgaanization’s definition of health as a state

of complete physical, mental, and social well-being, and not merely the

absence of disease and infirmity (George, 2008).

In Wiedenbach’s work, she incorporates the environment within the

realities- a major component of her theory. One element of the realities is

the framework. According to Wiedenbach (1970), the framework is a

complex of extraneous factors and circumstances that are present in every

nursing situation. The framework may include objects “such as policies,

setting, atmosphere, time of day, humans, and happenings” (George, 2008).

According to Wiedenbach (1969), nursing, a clinical discipline, is a

practice discipline designed to produce explicit desired results. The art of

nursing is a goal directed activity requiring the application of knowledge and

skill toward meeting a need for help experienced by a patient. Nursing is a

helping process that will extend or restore the patient’s ability to cope with

demands implicit in the situation (George, 2008).

CONCEPTUAL FRAMEWORK

Ernestine Wiedenbach, a progressive nursing leader, began her nursing

career in the 1920s. Wiedenbach first published Family-centered maternity

nursing in 1958. It is of interest that in that book she recommended that

babies be in hospital rooms with their mothers rather than in a central

nursery. This innovative concept was not widely implemented until 20 years

later. In 1964 she wrote Clinical nursing-A helping art in, which she described

her ideas about nursing as a “concept and philosophy” derived from 40

years of nursing experience (George, 2008).

Ernestine Wiedenbach concentrated on the art of nursing and focused

on the needs of the patient. Wiedenbach (1964) stated, “People may differ in

their concept of nursing, but few would disagree that nursing is nurturing or

caring for someone in motherly fashion. Wiedenbach specified the following

four elements: (1) philosophy, (2) purpose, (3) practice, and (4) art. She

postulated that clinical nursing is directed toward meeting the patient’s

perceived need-for-help (Tomey, 1994). That care is given in the immediate

present and can be given by any caring person. Nursing is a helping service

that is rendered with compassion, skill, and understanding to those in need

of care, counsel, and confidence in the area of health (Wiedenbach, 1977)

(George, 2008).

Nursing wisdom is acquired through meaningful experience

(Wiedenbach, 1964). Sensitivity alerts the nurse to an awareness of

inconsistencies in a situation that might signify a problem. It is a key factor

in assisting the nurse to identify the patient’s need for help (Wiedenbach,

1977) (George, 2008).

The nurse’s beliefs and values regarding reverence for the gift of life,

the worth of the individual, and the aspirations of each human being

determine the quality of the nursing care. The nurse’s purpose in nursing

represents a professional commitment (Wiedenbach, 1970) (George, 2008).

Wiedenbach (1964) states the characteristics of a professional person

that are essential for the professional nurse include the following (George,

2008):

1. Clarity of purpose.

2. Mastery of skills and knowledge essential for fulfilling the purpose.

3. Ability to establish and sustain purposeful working relationships with

others, both professional and nonprofessional individuals.

4. Interest in advancing knowledge in the area of interest and in creating

new knowledge.

5. Dedication to furthering the good of mankind rather than to self-

aggrandizement.

Wiedenbach believed that every individual experiences needs as a

normal part of living. A need is anything the individual may require “to

maintain or sustain himself comfortably or capably in his situation”. An

attempt to meet the need is made by the intervention of help, which is “any

measure or actions that enable the individual to overcome whatever

interferes with his ability to function capably in relation to his situation. . . To

be meaningful, help must be used by an individual and must succeed in

enhancing or extending his capability. Wiedenbach combines these two

definitions into a more critical concept for her theory of a Need-for-Help. It is

crucial to the nursing profession that a Need-for-Help is based on the

individual’s perception of his own situation. If the individual does not

perceive a need as need-for-help, he or she may not take action to relieve or

resolve it (Tomey, 1994).

Wiedenbach’s philosophy of practice is influenced by her conception of

nursing is an art. Barnum (1994) quoted that Wiedenbach believed that the

intention of the nurse was an important part of her effectiveness, that the

same act done with caring and without caring could have a different

outcome (Tomey, 1994).:

Barnum (1994) quoted that Wiedenbach states that it is the

nurse’s way of giving a treatment, for example, that enables a patient

to benefit for it, not just the fact that a treatment is given him; and it is

her way of expressing her concern – not just the fact that she is

present or speaks – that enables him to reveal his fears. The nurse’s

way of using the means available to her to achieve the results she

desires in her practice is an individual matter, determined to a large

degree, by her central purpose in nursing and the prescription she

regards as appropriate to its fulfillment.

According to Wiedenbach,, as quoted by Barnum (1994), the

nurse is a functioning human being. As such she not only acts, but she

thinks and feels as well. The thoughts she thinks and the feelings she

feels as she goes about her nursing is important; they are intimately

involved not only in what she does but also in how she does it. They

underlie every actions she takes, be in the form of spoken word, a

written communication, a gesture, or a deed of any kind, for the nurse

whose action is directed toward achievement of a specific purpose,

thoughts and feelings have a discipline role to play.

Barnum (1994) cited that Wiedenbach claimed that the thoughts

and feelings, including reactions, are integral parts not only of what we

do or say but also of how we do it… The thoughts and feelings that

precede and accompany each act are the less apparent parts of

nursing; yet, because they set direction for each act, they are the real

determiners of the results the nurse achieves.

According to Barnum (1994), Wiedenbach analyzed the “invisible” act

of caring and found that it was a tool that could be used to the nurse’s

advantage, ensuring her successful practice.

According to Wiedenbach, as stated by Barnum (1994), the secret of

the helping art of nursing lies in the importance the nurse attaches to

her thoughts and feelings and the deliberate use she makes of them as

she observes her patient, identifies his need for help, ministers to his

need and validates that the help she gave was helpful. If she

recognizes her thoughts and feelings, respects their importance, and

disciplines herself to harness them to her purpose and her philosophy,

not only will she enrich her nursing practice, but she will in all

probability experience enduring satisfaction from the helping service

she has rendered.

According to Barnum (1994), what Wiedenbach called concern is what

we label caring. And although she explored these feelings methodically, this

is not the way we usually think about the caring part of nursing.

According to Wiedenbach, the art of clinical nursing is directed toward

achievement of four main goals: (1) understanding of the patient and his

condition, situation, and need; (2) enhancement of the patient’s capability;

(3) improvement of his condition or situation within the framework of the

medical plans for his care; and (4) prevention of the recurrence of his

problem or development of a new one which may cause anxiety, disability or

distress. (Tomey, 1994).

THEORETICAL ASSERTIONS

The practice of nursing comprises a wide variety of services, each

directed toward the attainment of one of its three components: (1)

identification of the patient’s need for help, (2) ministration of the help

needed, and (3) validation that the help provided was indeed helpful to the

patient (Wiedenbach, 1977). Within Wiedenbach’s (1964) “identification of

the patient’s need for help,” she presents these principles of helping: (1) the

principle of inconsistency/consistency, (2) the principle of purposeful

perseverance, and (3) the principle of self-extension. The principle of

inconsistency/ consistency refers to the assessment of the patient to

determine some action, word, or appearance that is different from the

expected-that is, something out of the ordinary for this patient. It is

important for the nurse to observe the patient astutely and then critically

analyze her observations. The principle of purposeful perseverance is based

on the nurse’s sincere desire to help the patient. The nurse needs to strive to

continue her efforts to identify and meet the patient’s need for help in spite

of difficulties she encounters while seeking to use her resources and

capabilities effectively and with sensitivity. The principle of self-extension

recognizes that each nurse has limitations that are both personal and

situational. It is important that the nurse recognizes when these limitation

are reached and that she seek help from others, including through prayer

(George, 2008).

Wiedenbach affirmed that identification of the patient’s need-for-help

involves four steps. First, the nurse uses powers of observation to look and

listen for actual consistencies and inconsistencies in the patient’s behavior

compared with the nurse’s expectations for patient behavior. Second, the

nurse explores the meaning of the patient’s behavior with the patient. Third,

the nurse determines the cause of the patient’s discomfort or incapability.

Finally, the nurse determines whether the patient can resolve his or her

problem or if the patient has a need-for-help (Tomey, 1994).

Wiedenbach stated that ministration of needed help involves the nurse

making a plan to meet patient needs and presenting it to the patient. If the

patient concurs with the plan and accepts suggestions for implementing it,

the nurse implements it and ministration of needed help occurs. If the

patient does not concur with the plan or accept suggestions for

implementation, the nurse needs to explore the patient’s nonacceptance. If

the patient has a need-for-help, the nurse once again forms a plan to meet

the need, presents the plan, and seeks patient concurrence and acceptance

of suggestions for implementation (Tomey, 1994).

Wiedenbach posits the validation that the need-for-help was met is

important. The nurse perceives whether the patient’s behavior is consistent

with nurse’s concept of comfort and seeks clarification from the patient to

determine whether he or she believes the need-for-help was met. Then the

nurse needs to take appropriate action on the basis of the feedback (Tomey,

1994).

WIEDENBACH’S PRESCRIPTIVE THEORY

Theory may be described as a system of conceptualizations invented to

some purpose. Prescriptive theory (a situation-producing theory) may be

described as one that conceptualizes both a desired situation and the

prescription by which it is to be brought about. Thus, a prescriptive theory

directs action toward an explicit goal. Wiedenbach’s (196) prescriptive

theory is made up of three factors, or concepts (George, 2008):

1. The central purpose which the practitioner recognizes as essential to

the particular discipline.

2. The prescription for the fulfillment of the central purpose.

3. The realities in the immediate situation that influence the fulfillment of

the central purpose.

The Central Purpose

The nurse’s central purpose defines the quality of health she desires to effect

or sustain in her patient and specifies what she recognizes to be her special

responsibility in caring for the patient (Wiedenbach, 1970). This central

purpose (or commitment) is based on the individual nurse’s philosophy.

Wiedenbach (1964) states (George, 2008):

Purpose and philosophy are, respectively, goal and guide of

clinical nursing… Purpose-that which the nurse wants to

accomplish through what she does-is the overall goal toward

which she is striving, and so is constant. It is her reasons for

being and doing… Philosophy, an attitude toward life and reality

that evolves from each nurse’s beliefs and code of conduct,

motivates the nurse to act, guides her thinking about what she is

to do and influences her decisions. It stems from both her culture

and subculture, and is an integral part of her. It is personal in

character, unique to each nurse, and expressed in her way of

nursing. Philosophy underlies purpose, and purpose reflects

philosophy.

Wiedenbach (1970) identifies three essential components for a nursing

philosophy: (1) a reverence for the gift of life, (2) a respect for the dignity,

worth, autonomy, and individuality of each human being, and (3) a resolution

to act dynamically in relation to one’ beliefs. Any of these concepts might be

further developed. However, Wiedenbach (1964, 1970) emphasizes the

second in her work, formulating the following beliefs about the individual

(George, 2008):

1. Human beings are endowed with unique potential to develop within

themselves the resources that enable them to maintain and sustain

themselves.

2. Human beings basically strive toward self-direction and relative

independence, and desire not only to make the best use of their

capabilities and potentialities but also to fulfill their responsibilities.

3. Human beings need stimulation in order to make the best use of their

capabilities and realize their self-worth.

4. Whatever individuals do represent their best judgment at the moment

of doing it.

5. Self-awareness and self-acceptance are essential to the individual’s

sense of integrity and self-worth.

Thus, the central purpose is a concept the nurse has thought through-one

she has put into words, believes in, and accepts as a standard against which

to measure the value of her action to the patient (George, 2008).

The Prescription

Once the nurse has identified her own philosophy and recognizes that the

patient has autonomy and individuality, she can work with the individual to

develop a prescription or plan for his or her care (George, 2008).

A prescription is a directive activity (Wiedenbach, 1969). It “specifies

both the nature of the action that will most likely lead to fulfillment of the

nurse’s central purpose and the thinking process that determines it”

(Wiedenbach, 1970). A prescription may indicate the broad general action

appropriate to implementation of the basic concepts as well as suggest the

kind of behavior needed to carry out these actions in accordance with the

central purpose. These actions may be voluntary or involuntary. Voluntary

action is an intended response, whereas involuntary action is an unintended

response (George, 2008).

A prescription is a directive to at least three kinds of voluntary action:

(1) Mututally understood and agreed upon action (“the practitioner has . . .

evidence that the recipient understands the implications of the intended

action and is psychologically, physically and/or physiologically receptive to

it.”; (2) recipient-directed action (“the recipient of the action essentially

directs the way it is to be carried out.”); and (3) practitioner-directed action

(“the practitioner carries out the action . . . .”)(Widenbach, 1969). Once the

nurse has formulated a central purpose and has accepted it as a personal

commitment, she not only has established the prescription for her nursing

but also is ready to implement it (Wiedenbach, 1970) (George, 2008).

The Realities

When the nurse has determined her central purpose and has developed the

prescription, she must then consider the realities of the situation in which

she is to provide nursing care. Realities consist of all factors—physical,

physiological, psychological, emotional, and spiritual—that are at play in

situation in which nursing actions occur at any given moment. Wiedenbach

(1970) defines the five realities as: (1) the agent, (2) the recipient, (3) the

goal, (4) the means, and (5) the framework (George, 2008).

The agent, who is the practicing nurse or her delegate, is characterized

by personal attributes, capacities, capabilities, and most importantly,

commitment and competence in nursing. As the agent, the nurse is the

propelling force that moves her practice toward its goal. In the course of this

goal-directed movement, she may engage in innumerable acts called forth

by her encounter with actual or discrepant factors and situations within the

realities of which she herself is a part (Widenbach, 1967). The agent or nurse

has the following four basic responsibilities(George, 2008):

1. To reconcile her assumptions about the realities. . . with her central

purpose.

2. To specify the objectives of her practice in terms of behavioral

outcomes that are realistically attainable.

3. To practice nursing in accordance with her objectives.

4. To engage in related activities which contribute to her self-

realization and to the improvement of nursing practice

(Wiedenbach, 1970).

The recipient, the patient, is characterized by personal attributes,

problems, capacities, aspirations, and most important, the ability to cope

with the concerns or problems being experienced (Wiedenbach, 1967). The

patient is the recipient of the nurse’s actions or the one on whose behalf the

action is taken. The patient is vulnerable, dependent on others for help, and

risks losing individually, dignity, worth, and autonomy (Wiedenbach, 1970)

(George, 2008).

The goal is the desired outcome the nurse wishes to achieve. The goal

is the end result to be attained by nursing action. The stipulation of an

activity’s goal gives focus to the nurse’s action and implies her reason for

taking it (Wiedenbach, 1970) (George, 2008).

The means comprises the activities and devices through which the

practitioner is enabled to attain her goal. The means includes skills,

techniques, procedures, and devices that may be used to facilitate nursing

practice. The nurse’s way of giving treatments, of expressing concern, of

using the means available is individual and is determined by her central

purpose and the prescription (Wiedenbach, 1970) (George, 2008).

The framework consists of the human, environmental, professional,

and organizational facilities that not only make up the context within which

nursing is practiced but also constitue its currently existing limits

(Wiedenbach, 1967). The framework is composed of all the extraneous

factors and facilities in the situation that affect the nurse’s ability to obtain

the desired results. It is a conglomerate of “objects, existing or missing, such

as policies, setting, atmosphere, time of day, humans, and happenings, that

may be current, pas, or anticipated” (Wiedenbach, 1970) (George, 2008).

The realities offer uniqueness to every situation. The success of

professional nursing practice is dependent on them. Unless the realities are

recognized and dealt with, they may prevent the achievement of the

goal(George, 2008).

The concepts of central purpose, prescription, and realities are

interdependent in Wiedenbach’s theory of nursing. The nurse develops a

prescription for care that is based on her central purpose, which is

implemented in the realities of the situation(George, 2008).

WIEDENBACH’S CONCEPTUALIZATION OF NURSING PRACTICE AND

PROCESS

According to Wiedenbach (1967), nursing practice is an art in which the

nursing action is based on the principles of helping. Nursing action may be

thought of as consisting of the following four distinct kinds of actions

(George, 2008):

Reflex (Spontaneous)

Conditioned (Automatic)

Impulsive (Impulsive)

Deliberate (Responsible)

Nursing as a practice discipline is goal-directed. The nature of the

nursing act is based on thought. The nurse thinks through the kind of results

she wants, gears her actions to obtain those results, then accepts

responsibility for the acts and the outcome of those acts (Wiedenbach,

1970). Since nursing requires thought, it can be considered a deliberate

responsible action (George, 2008).

Nursing practice has three components: (1) identification of the

patient’s need for help, (2) ministration of the help needed, and (3)

validation that the action taken was helpful to the patient (Wiedenbach,

1977). Within the identification component, there are four distinct steps.

First, the nurse observes the patient, looking for an inconsistency between

the expected behavior of the patient and the apparent behavior. Second, she

attempts to clarify what the inconsistency means. Third, she determines the

cause of the inconsistency. Finally, she validates with the patient that her

help is needed (George, 2008).

The second component is the ministration of the help needed. In

ministering to her patient, the nurse may give advice or information, make a

referral, apply a comfort measure, or carry out a therapeutic procedure.

Should the patient become uncomfortable with what is being done, the nurse

will need to identify the cause and, if necessary, make an adjustment in the

plan of action (George, 2008).

The third component is validation. After help has been ministered, the

nurse validates that the actions were indeed helpful. Evidence must come

from the patient that the purpose of the nursing actions has been fulfilled

(Wiedenbach, 1964) (George, 2008).

Wiedenbach (1977) views the nursing process essentially as an

internal personalized mechanism. As such, it is influenced by the nurse’s

culture, purpose in nursing, knowledge, wisdom, sensitivity, and concern

(George, 2008).

In Wiedenbach’s (1977) nursing process, she identifies seven levels of

awareness: sensation, perception, assumption, realization, insight, design,

and decision. Wiedenbach’s nursing process begins with an activating

situation. This situation exists among the realities and serves as a stimulus

to arouse the nurse’s consciousness. This consciousness arousal leads to a

subjective interpretation of the first three levels, which are defined as:

sensation (experienced sensory impression), perception (the interpretation

of a sensory impression), and assumption (meaning the nurse attaches to

the perception). These three levels of awareness are obtained through the

focus of the nurse’s attention on the stimulus: they are intuitive rather than

cognitive and may initiate an involuntary response. For example, a nurse

enters a patient’s room and states, “My, it’s hot in here!” She immediately

goes to the thermostat and sets it to a lower temperature. The sensation is

the room temperature. The perception is “It feels hot”. The assumption is “If

I am hot, the patient must be hot”. The involuntary response is to adjust the

thermostat (George, 2008).

Progressing from intuition to cognition, the nurse’s actions become

voluntary rather than involuntary. The next four levels of awareness occur in

the voluntary phase: realization (in which the nurse begins to validate the

assumption previously made about the patient’s behavior); insight (which

includes joint planning and additional knowledge about the cause of the

problem); design (the plan of action decided on by the nurse and confirmed

by the patient); and decision (the nurse’s performance of a responsible

action) (Wiedenbach,1977) (George, 2008).

To continue with the previous example: the nurse ask, “Are you too

warm?” and the patient replies, “No, I’m not. I have felt cold since I washed

my hair”. The nurse responds, “I will readjust the thermostat and get you a

blanket”. The patient agrees, “That would be wonderful!” The nurse

readjusts the thermostat and gets a blanket for the patient (George, 2008).

The realization is the validation of the patient’s perception of

temperature comfort. The insight is the additional information that the

patient had washed his or her hair. The design is the plan to readjust the

thermostat and get a blanket as confirmed by the patient. The decision is the

nurse readjust the thermostat and gets a blanket for the patient (George,

2008).

In summary, the comparison of Wiedenbach’s prescriptive theory, the

practice of nursing, and the nursing process as outlined in Chapter 2 of this

book is as follows: in the practice of nursing, a nurse with her unique

personality, philosophy, education, and life experiences (her central

purpose), assesses the individual’ health status and potential for

development. She identifies the patient’s need for help (makes a nursing

diagnosis). She formulates a plan with the patient, identifying outcomes and

setting goals affected by the realities, or the strengths and limitations of the

situation (the environment). Their plan is implemented or the nurse provides

the help needed. Validation is then obtained that the help provided was

indeed helpful to the patient (evaluation) (George, 2008).

III. THEORY SYTHESIS

WIEDENBACH’S THEORY AND CLINICAL PRACTICE

Wiedenbach consistently emphasized “purpose and “patient” in her many

writings and presentations about her perspective of nursing practice. She

stated: “The practice of clinical nursing is goal directed, deliberately carried

out and patient centered”. (Wiedenbach, 1964). Figure 6-1 represents a

spherical odel she created in 1962 that depicts the “experiencing individual”

as the central focus. In a presentation entitled “A Concept of Dynamic

Nursing” at a conference in Pittsburgh, Pennsylvania (Wiedenbach, 1962),

she described the model as follows (Parker, 2001):

In its broadest sense,

Practice of Dynamic

Nursing may be

envisioned as a set of

concentric circles,

with the experiencing

individual in the circle

at its core. Direct

service, with its three

components, identification of the individual’s experienced need

for help, ministration of help needed and validation that the help

provided fulfilled its purpose, fills the circle adjacent to the core.

The next circle holds the essential concomitants of direct service’

coordination, i.e., charting, recording, reporting, and conferring;

consultation, i.e., conferencing, and seeking help or advice; and

collaboration, i.e., giving assistance or cooperation with

members of other professional or non-professional groups

concerned with the individual’s welfare. The content of the circle

represents activities which are essential to the ultimate well-

being of the experiencing individual, but only indirectly related to

him; nursing education, nursing administration and nursing

organizations. The outermost circle comprises research in

nursing, publication and advanced study, the key ways to

progress in every area of practice.

She explained the elements of the second sphere to her presentation

audience in the following way (Parker, 2001):

Implicit in identification is the individualization of the individual

and what he is experiencing. This calls for awareness of how the

individual differs in appearance, manner, and behavior, from any

other individual, and from the nurse’s expectation of him. It calls

for recognition too, that the individual’s perception of his

condition or situation grows out of his background of experiences

and understandings, which many be called his frame-of-

reference; while the nurse’s perception of it is in relation to her

background of experiences and understandings, that is, her

frame-of-reference. Activity in this unit of Practice

(identification)is directed toward ascertaining 1) whether the

individual is experiencing discomfort or incapability; 2) the cause

of the discomfort or incapability he may be experiencing; 3) the

need required to restore comfort or capability; and 4) whether

the need represents a need-for-help, one, in other words which

the individual is unable to meet himself, unaided.

The unit Ministration involves providing the help which is

needed. Underlying it, is the assumption that the individual must

be accepting of any applied resource, be it a bit of advice, a

recommendation, or a comfort or therapeutic measure, if he is to

derive maximum benefit from it. Application of resource, thus, is

dependent first of all, on selection of one which is appropriate to

the need which has been identified, and second, on its

acceptability to the individual. In this unit o Practice, i.e.,

Ministration-of-Help-Needed, the full range of resources to which

the nurse has access may come into play, and the greater her

stock of resources, the greater her potential for effective

services. Included in such range would be her own beliefs,

values, knowledge, skills and know-how; those of others whom

she knows or whom she has heard, i.e., members of other

professions or the laity; and those represented by facilities of the

community and beyond.

Validation has as its goal, evidence that, as a result of the

help that was provided, the individual is experiencing

improvement in his feeling of comfort and capability in relation

to his immediate situation. Such improvement may be measured

by the individual’s verbal and non-verbal behavior, on the

assumption that he will respond behaviorally, to how he is

currently experiencing his situation. Implicit in this unit are 1)

clarification of the meaning to the individual, of his behavior; and

2) classification of his meaning according to the nurse’s concept

of comfort and capability in the context of the individual’s

situation. Essentially, this means that to validate the

effectiveness of Practice, how the individual is experiencing his

immediate situation must be consistent with the nurse’s

expectation of the outcome of her ministration.

Wiedenbach’s clinical application of her prescriptive theory was always

evident in her logical clinical examples. They often related to general basic

nursing procedures, but more so with maternity nursing practice. In

discussing the practice and process of nursing, she stated (Parker, 2001):

The focus of Practice is the experiencing individual, i.e., the

individual for whom the nurse is caring, and the way he and only

he perceived his condition or situation. For example, a mother

had a red vaginal discharge on her first postpartum day. The

doctor had recognized it as lochi, a normal concomitant of the

phenomenon of involution, and had left an order for her to be up

and move about. Instead of trying to get up, the mother

remained, immobile in her bed. The nurse who wanted to help

her out of bed expressed surprise at the mother’s unwilling to do

so, when she seemed to be progressing so well. The mother

explained that she had a red discharge, and this to her was

evident of onset of hemorrhage. This terrified her and made her

afraid to move. Her sister, she added, had hemorrhaged and

almost lost her lfie the day after she had her baby two years ago.

The nurse expressed her understanding of the mother’s fear, but

then encouraged her to compare her current experience with

that of her sister. When the mother tried to do this, she

recognized gross differences, and accepted the nurse’s

explanation of the origin of the discharge. The mother then

voiced her relief, and validated it by getting out of bed without

further encouragement (Wiedenbach, 1962).

IV. THEORY DERIVIATION

The difference between a helping hand and an outstretched palm is a twist

of the wrist. 

~Laurence Leamer, King of the Night

As the saying goes, no man

is an island. Each person has

the tendency to have a

feeling of need and this need

may pertain to a person. As

nurses, patients turn to us

because they are in need of

something; be it physical,

emotional or even spiritual.

Our role as nurses is helping hands of God to those in need. Nurses should

have the sincerity and concern when using our helping hands because our

thoughts and feelings are expressed through our actions. If a nurse’s thought

and feeling is to give help to her patient because she is concerned with her

welfare, not just because it is in her job description, the patient would sense

the nurse’s concern. We nurses should not only offer our hands to help, but

also we have to offer our helping hands with the intention of augmenting the

health of the person. We should put in our hearts and minds the vocation this

profession entails. Nurses should define their purpose of entering nursing. It

is with their purpose that their actions would radiate their intentions. If the

purpose of the nurse is to promote health then that is what the patient would

feel. The purpose defined by the nurse would determine their interventions

and plans in the care of the patient.

Based from Wiedenbach’s theory, the role of the nurses is not merely

carrying out orders from physicians. We should learn to assess if the patient

is in need-of-help. The patient may not always verbalize this need-of-help

therefore implying that we nurses should be extra sensitive when it comes to

assessment of patients. We do not only base our observations with their

subjective cues but also we assess their objective cues.

Before nurses begin their day, it is essential that they determine their

objectives in working. A nurses’ objective must comprise of the sincerity of

providing the needs of the patient and not just because their job is asking

them to do. The nurses’ helping hand should always be ready in their

everyday encounter with patients because these people come to nurses

because they are in need-of-help.

V. BIBLIOGRAPHY

Barnum, B. (1994). Nursing Theory: Analysis, Application, Evaluation. 4th ed.

Philadelphia: J.B. Lippincott Company.

George, J. (2008). Nursing Theories: The Base for Professional Nursing

Practice. 5th ed. New Jersey: Prentice Hall.

Parker, M. (2001). Nursing Theories and Nursing Practice. Philadelphia: F.A.

Davis.

Tomey, A. (1994). Nursing theorist and their work. 5th ed. St. Louis, Missouri:

Mosby year book.

JEAN WATSON’S THEORY OF HUMAN CARING

I. INTRODUCATION

Above all, nursing is caring.

- Margaret Jean Herman Watson R.N., Ph.D.

The said quote connotes that nursing is geared towards providing care.

A nurse should prioritize caring as her primary role in dealing with her

patients and not merely by what her profession denotes. Nurses have to be

conscious of their significance and approach in serving their clients to

provide their utmost quality care.

In that same occasion, Dr. Watson proposed that nurses engage in a

regular practice of cultivating love and caring within themselves, and being

and becoming the Caritas Field, as a way of co-creating the profession's

future. She called upon nurses to come of age and establish nursing as a full

mature health, healing and caring profession, considering the current crisis

within healthcare.

According to Arnold and Boggs (1989), caring is a commitment by the

nurse to become involved since it is relational in character. Nurses enter the

experience with their whole being. It involves patients in their struggle for

health rather than simply doing those actions they cannot perform for

themselves. It includes the act of giving freely and willingly of oneself to

another through warmth, compassion, concern, and interest. Nurses care for

others during times of physical discomfort, emotional stress, and health

maintenance. As quoted by Arnold and Boggs (1989), Gaut claimed that

nurses express caring as concern for others, as exemplified in the statement,

“I care about your health,” as a responsibility, as in the statement, “I will be

caring for you today,” and as a fondness or attachment, as in the statement,

“I like you and care for you.”

The changes in the health care delivery systems around the world

have intensified nurses’ responsibilities and workloads. Nurses must now

deal with patients’ increased acuity and complexity in regard to their health

care situation. Despite such hardships, nurses must find ways to preserve

their caring practice and Jean Watson’s caring theory can be seen as

indispensable to this goal.

Being informed by Watson’s caring theory allows us to return to our

deep professional roots and values; it represents the archetype of an ideal

nurse. Caring endorses our professional identity within a context where

humanistic values are constantly questioned and challenged (Duquette &

Cara, 2000). Upholding these caring values in our daily practice helps

transcend the nurse from a state where nursing is perceived as “just a job,”

to that of a gratifying profession. Upholding Watson’s caring theory not only

allows the nurse to practice the art of caring, to provide compassion to ease

patients’ and families’ suffering, and to promote their healing and dignity but

it can also contribute to expand the nurse’s own actualization. In fact,

Watson is one of the few nursing theorists who consider not only the cared-

for but also the caregiver. Promoting and applying these caring values in our

practice is not only essential to our own health, as nurses, but its significance

is also fundamentally tributary to finding meaning in our work.

OBJECTIVES:

Upon successful completion of this discussion, the reader will be able to:

Describe the historical background of the development of Watson’s

theory

Define Watson’s Human Caring Theory and the Carative factors and

Clinical Caritas

Present the relationship between Watson’s theory and concepts in

nursing’s metaparadigm

Provide an example of use of Watson’s theory in clinical practice

II. THEORY ANALYSIS

HISTORICAL EVALUATION OF THE THEORY

The theory of Human Caring was developed between 1975 and 1979, while

Watson was engaged in teaching at the University of Colorado; it emerged

from her own views of nursing, combined and informed by her doctoral

studies in educational-clinical and social psychology. She tried to make

explicit nursing's values, knowledge, and practices of human caring that are

geared toward subjective inner healing processes and the life world of the

experiencing person, requiring unique caring-healing arts and a framework

called "carative factors," which complemented conventional medicine, but

stood in stark contrast to "curative factors." At the same time, this emerging

philosophy and theory of human caring sought to balance the cure

orientation of medicine, giving nursing its unique disciplinary, scientific, and

professional standing with itself and its public (Parker, 2002).

Watson’s work embraces concepts of mind and other concepts.

Watson’s philosophy and theory of human caring are concerned with spirit

rather than matter, flux rather than form, inner knowledge, and power rather

than circumstance (Alligod and Tomey, 2002).

Watson referred to caring as the essence of nursing practice. It is a

moral ideal rather than a task-oriented behavior and includes such

characteristics as the actual caring occasion and the transpersonal caring

moment, phenomena that occur when an authentic caring relationship exists

between the nurse and the patient. She views nursing and caring as “both as

human science and an art, and as such cannot be considered qualitatively

continuous with traditional, reductionistic, scientific methodology” (Tomey,

1994).

BACKGROUND OF THE THEORIST

Dr. Jean Watson is Distinguished Professor of Nursing and holds an endowed

Chair in Caring Science at the University of Colorado Denver and Anschutz

Medical Center Campus. She is founder of the original Center for Human

Caring in Colorado and is a Fellow of the American Academy of Nursing.  She

previously served as Dean of Nursing at the University Health Sciences

Center and is a Past President of the National League for Nursing. Her latest

activities include Founder and Director of a new non-profit foundation:

Watson Caring Science Institute (Parker, 2002).

Jean Watson was born in a small, close-knit town in the Appalachian

Mountains of West Virginia in the 1940s. Jean Watson graduated from the

Lewis Gale School of Nursing in Roanoke, Virginia, in 1961. She continued

her nursing studies at the University of Colorado at Boulder, earning a B.S. in

1964, an M.S. in psychiatric and mental health nursing in 1966, and a Ph.D.

in educational psychology and counseling in 1973. She is a widely published

author and recipient of several awards and honors, including an international

Kellogg Fellowship in Australia, a Fulbright Research Award in Sweden. She

holds eight (8) Honorary Doctoral Degrees, including 5 International

Honorary Doctorates (Sweden, United Kingdom, Spain, British Colombia and

Quebec, Canada).

She has been Distinguished Lecturer and Endowed Lecturer at

universities throughout the United States and been around the world several

times. Clinical nurses and academic programs throughout the world use her

published works on the philosophy and theory of human caring and the art

and science of caring in nursing (Parker, 2002). 

Dr. Watson’s caring philosophy is used to guide transformative models

of caring and healing practices for nurses and patients alike, in diverse

settings worldwide.  Watson has been featured in numerous national videos

on nursing theory and the art of nursing.  She is the recipient of several

national awards, including The Fetzer Institute Norman Cousins Award, in

recognition of her commitment to developing; maintaining and exemplifying

relationship-centered care practices (Parker, 2002). 

As author /co-author of over 14 books on caring, her latest books range

from empirical measurements of caring, to new postmodern philosophies of

caring and healing. Her books have been AJN books of the year awards, seek

to bridge paradigms as well as point toward transformative models for the

21st century. A new revised edition of her first book, Nursing The Philosophy

and Science of Caring is now available - (www.upcolorado.com) A new

edition of Assessing and Measuring Caring was published in September, 2008

(Springer Publication, NY). Currently she is working on a new revised work on

‘Creating a Caring Science Curriculum for Caring Science’ (Springer in

progress) (Parker, 2002).

In 2008 Dr. Watson created a non-profit foundation: Watson Caring

Science Institute, to further the work of Caring Science in the world (Parker,

2002).

APPROACH TO THE DEVELOPMENT OF THE MODEL

WATSON’S THEORY AND NURSING’S METAPARADIGM

Watson’s earlier works address the metaparadigm concepts of person

(human being), health, environment, and nursing as somewhat more

discrete concepts than do her later works. As Watson has been inspired by

quantum physics and has integrated varied ways of knowing and being and

doing, her descriptions of the metaparadigm concepts have been modified.

The concepts are dealt with as nondiscrete, intertwined, and discontinuous

(George, 2008).

Person (Human Being)

Considering the individual human, Watson (1985/88) views (George, 2008):

the human as a valued person in and of him- or herself… in general a

philosophical view of a person as a fully functional integrated self…

greater than, and different from, the sum of his or her parts”.

Furthermore, essential to human existence “is that the human has

transcended nature-yet remains part of it. The human can go forward,

through the use of the mind, to higher levels of consciousness… one’s

soul possesses a body that is not confined by objective space and time.

In 1996, Watson elaborated on this transcendent nature of being

human. She uses a quote of de Chadrin (1967) (George, 2008):

We are not human beings having a spiritual experience.

We are spiritual beings having a human experience.

Of the basic premises identified by Watson (1985/88) on which her

caring model is based, five relate to person (George, 2008).

1. A person’s mind and emotions are windows to the soul…

2. A person’s body is confined in time and space, but the mind and soul

are not confined to the physical universe…

3. A nurse may have access to a person’s mind, emotions, and inner self

indirectly through any sphere-mind, body or soul-provided the physical

body is not perceived or treated as separate from the mind and

emotions and higher sense of self (soul)…

4. The spirit, inner self, or soul (geist) of a person exists in and for itself…

5. People need each other in a caring, loving way…

In more recent work (1996), Watson’s focus shifts more to the

connectedness of all existence. She further develops the concept of the

“unity of mindbodyspirit/ nature, and of a field of connectedness between

and among persons and environments at all levels, into infinity and into the

universal or cosmic level of existence”. There is an “Unbroken wholeness

and connectedness of all (subject-object-person-environment-nature-

universe- all living things)”. This expanded view of what it means to be

human, to be healed, and to be whole, considers person to be “embodied

spirit, both immanent and transcendent” (George, 2008).

Health and Illness

Watson considers illness to be a perceived state rather than presence of

disease. Illness is defined as (George, 2008):

Subjective turmoil or disharmony within a person’s inner self or

soul at some level or disharmony within the spheres of the

person, for example, in the mind, body, and soul, either

consciously or unconsciously… Illness connotes a felt

incongruence within the person such as an incongruence

between the self as perceived and the self as experienced

(Waston, 1985/ 1988).

Watson notes that illness can result from a troubled inner soul, and illness

can lead to disease, but the two concepts do not fall on a continuum and can

exist apart from one another (George, 2008)r.

Watson’s definition of health, on the other hand, does imply a health-

illness continuum. As described in her 1985/1988 work (George, 2008):

Health refers to unity and harmony within the mind, body, and

soul. Health is also associated with the degree of congruence

between the self as perceived and the self as experienced.

Encompassing the entire nature of the individual in the physical, social,

aesthetic, and moral realms, rather than limited to aspects of behavior and

physiology, health or illness results from the congruence or incongruence

between the self as perceived and the self as experienced. Disease may

result from or be a causal factor in prolonged periods of incongruence. Or,

disease may not be present (George, 2008).

Environment

In 1996, Watson reiterated the usefulness of her ten carative factors,

originally presented in 1979. One of these factors speaks to environment.

Carative factor 8 is: “Attending to supportive, protective, and/ or corrective

mental, physical, societal, and spiritual environments”. However, in

discussions of her more recent thought, environment is considered in the

context of a human-environment field. As noted above, this field form an

“Unbroken wholeness and connectedness of all (subject-object-person-

environment-nature-universe-all living things)” (Watson 1996). It seems,

then, that environment can be perceived to be a specific context, such as

social, physical, or as the greater context, such as social, physical, or as the

greater context of interacting, nondiscrete elements within a phenomenal

field (George, 2008).

Nursing as Profession and Praxis

In her own words, Watson (1985/ 1988) defined nurse to be both a noun and

a verb, and nursing to consist (George, 2008):

of knowledge, thought, values, philosophy, commitment, and

action with some degree of passion… related to human care

transactions and intersubjective personal human contact with

the lived world of the experiencing person.

The verb “to nurse” is carried out through human care and caring, which

Watson views as the moral ideal of nursing and (George, 2008):

consists of transpersonal human-to-human attempts to protect,

enhance, and preserve humanity by helping a person find

meaning in illness, suffering, pain, and existence; to help another

gain self-knowledge, control, and self-healing wherein a sense of

inner harmony is restored regardless of the external

circumstances.

Human care nursing involves a reciprocal relationship between the

nurse and others as coparticipants in a pattern of subjectivity-

intersubjectivity evidenced in “consciousness; intentionality; perceptions and

lived experiences related to caring, healing, and health-illness condition in a

given ‘caring moment’; and experience or meanings that transcend the

moment and go beyond the actual experience” (Watson, 1996) (George,

2008).

Watson (1996) determines nursing to be both scientific and artistic,

based on caring-healing knowledge and practices drawn from the arts and

humanities as well as from traditional and emerging sciences. As a

profession, nursing “exists in order to sustain caring, healing, and health

where, and when, they are threatened biologically, institutionally,

environmentally, or politically, by local, national, or global influences”

(George, 2008).

The practice of nursing based on Watson’s theoretical and

philosophical concepts differs substantially from biomedical/ natural-science

based practice. The physical body is cared for, but the care is never

separated from the context of the unity of mindbodyspirit/nature (George,

2008).

OVERVIEW OF WATSON’S PHILOSOPHY OF HUMAN CARING

Watson’s notions of personhood and life are based on the concept of human

being as embodied spirit. Within a transpersonal framework, the body is a

living spirit that manifests one’s being in the world and one’s way of standing

and reflects how one holds oneself with respect to one’s relation to self and

one’s consciousness or unconscious. The human soul (also called spirit, geist,

or higher sense of self) transcends the physical, mental, and emotional

existence of a person at any given time. The soul and spirit are those

aspects of consciousness that are not confined by objective space and time

and that are unconstrained by linearity. By acknowledging a spiritual

dimension to life, Watson is able to speculate on the human capacity to

coexist with past, present and future in the moment. She respects the

dignity, reverence, chaos, mystery and wonder of life because of the

continuous yet unknown journey the soul takes, through the infinite and

eternal. Watson view soul as

the essence of the person, which possess a greater sense of self

awareness, a higher(ascent) degree of consciousness, an inner

strength, and a power that can expand human capacities and allow a

person to transcend his or her usual self. From this higher sense of

consciousness (soul level), one can more fully access the intuitive,

deep imagination, the uncanny, the mystical, dream work, and

feminine/masculine archetypes, and can come to “be” utilizing modes

of awareness, feeling, and experience the rational scientific culture

inhibit (Alligod and Tomey, 2002).

Watson affirmed that “Human life is defined as being in the world,

which is continuous in time and space.” The locus of human existence is

experience. Broadly defined, experience includes sensory motor experience,

mental/emotional experience, and spiritual experience. Experience is

translated through multiple layers of awareness. Consciousness has the

capacity to create and construct (Alligod and Tomey, 2002).

Watson said the person is a living, growing gestalt that possesses

three spheres of being-body, mind and soul-which are influenced by the

concept of self. The mind and emotions are the starting point and the point

of access to the subjective world. The self is the subjective center that lives

within the whole body, thoughts, sensations, desires, memories, life history,

and so forth (Alligod and Tomey, 2002).

Watson stated Intentionality is the projection of awareness or

consciousness with some purpose and efficacy toward some object or

outcome. One’s intention and attention shape experiences, as parts of the

evolutionary ontological process. Watson has said, “if our conscious

intentionality is to hold thoughts that are caring, open, loving, kind and

receptive, in contrast to an intentionality to control, manipulate and have

power over, the consequences will be significant for our actions (Alligod and

Tomey, 2002).

MAJOR CONCEPTUAL ELEMENTS

The major conceptual elements of the original and emergent theory are

(Parker, 2002):

Carative Factors (evolving toward "Clinical Caritas Processes")

Transpersonal Caring Relationship

Caring Moment/Caring Occasion

Caring-healing modalities

Other dynamic aspects of the theory which are emerging as more explicit

components include (Parker, 2002):

• Expanded views of self and person (transpersonal mindbodyspirit unity

of being; embodied spirit;

• Caring-Healing Consciousness and intentionality to care and promote

healing;

• Caring consciousness as energy within the human environment field of

a caring moment;

• Phenomenal field/unitary consciousness: unbroken wholeness and

connectedness of all;

• Advanced caring-healing modalities/nursing arts as a future model for

advanced practice of nursing qua nursing; (consciously guided by one’s

nursing theoretical-philosophical orientation);

Original and Evolving Ten Carative Factors

The original 1979 work was organized around ten carative factors as a

framework for providing a format and focus for nursing phenomena. While

"carative factors" are still the current terminology for the "core" of nursing,

providing a structure for the initial work, the term "factor" is too stagnant for

my sensibilities today. Watson offers another concept today that is more in

keeping with Watson’s own evolution and future directions for the "theory".

Watson offers the concept of "clinical caritas" and "caritas processes" as

consistent with a more fluid and contemporary movement with these ideas

and her expanding directions (Parker, 2002).

Clinical Caritas and Caritas Processes

"Caritas" comes from the Greek word meaning to cherish, to appreciate, to

give special attention, if not loving, attention to; it connotes something that

is very fine that indeed is precious. The word "caritas" also is closely related

to the original word "carative" from Watson’s 1979 book. At this time Watson

makes new connections between carative, caritas and without hesitation

invoke the "L" word, which caritas conveys, that is love, allowing love and

caring coming together for a new form of deep transpersonal caring. This

relationship between love and caring connotes inner healing for self and

others, extending to nature, and the larger universe, unfolding and evolving

within a cosmology that is both metaphysical and transcendent with the co-

evolving human in the universe (Watson, 1998) (Parker, 2002).

"Clinical Caritas" is an emerging model of transpersonal caring and

moves from carative to caritas. This integrative expanded perspective is

both postmodern, in that it transcends conventional industrial, static models

of nursing, while simultaneously evoking both the past and the future. For

example, the future of nursing is ironically tied back to Nightingale’s sense of

"calling", guided by a deep sense of commitment and a covenantal ethic of

human service; cherishing our phenomena, our subject matter, and those we

serve. It is when we include caring and love in our work and our life that we

discover and affirm that nursing, like teaching, is more than just a job, but a

life-giving and life-receiving career for a lifetime of growth and learning.

Such maturity and integration of past with present and future, now require

transforming self, and those we serve, including our institutions, and the

profession itself. As we more publicly and professionally assert these

positions for our theories, our ethics and our practices, even our science, we

also locate ourselves and our profession and discipline within a new,

emerging cosmology. Such thinking calls for a sense of reverence and

sacredness with regard to life and all living things (Parker, 2002).

It incorporates both art and science, as they are also being redefined,

acknowledging a convergence between art, science, and spirituality. As one

enters into the transpersonal caring theory and philosophy, one

simultaneously is challenged to relocate themselves in these emerging ideas

and question for themselves how the theory speaks to them, inviting them

into a new relationship with themselves and their ideas about life, nursing,

and theory. In this framework each one is also asked, if not enticed to

examine and explore the critical intersection between the personal and the

professional; to translate their unique talents, interests, and gifts into human

service of caring and healing, for self and others, and even the planet Earth

itself (Parker, 2002).

Original Carative Factors

The original carative factors served as a guide to what was referred to as the

"core of nursing", in contrast to nursing’s "trim". Core pointed to those

aspects of nursing that potentiate therapeutic healing processes and

relationships; they affect the one caring and the one-being-cared-for.

Further, the basic core was grounded in what I referred to as the philosophy,

science, and art of caring. Carative is that deeper and larger dimension of

nursing that goes beyond the "trim" of changing times, setting, procedures,

functional tasks, specialized focus around disease, treatment and

technology. While the "trim" is important and not expendable, the point is

that nursing cannot be defined around its trim and what it "does" in a given

setting at a given point in time. Nor can nursing’s trim define and clarify its

larger professional ethic and mission to society - its raison d’etre for the

public. That is where nursing theory comes into play and transpersonal

caring theory offers another way, that both differs from, yet complements,

that which has come to be known as "modern" nursing and conventional

medical-nursing frameworks (Parker, 2002).

Watson regards the carative factors as the foundation for “advanced

practices and caring modalities for healing and health processes and

outcomes.” Moreover, Watson viewed the Carative Factors as both

hierarchical in nature, whereby each preceding factor contributes to the next

one and interacting to promote holistic nursing care. The first and most basic

carative factor, Forming a Humanistic-Altruistic System of Values,

points out that human caring is, according to Watson, grounded on universal

humanistic and altruistic values. Furthermore, she claimed that the best

professional care is promoted when the nurse subscribes to such a value

system. With regard to the second carative factor, Enabling and

Sustaining Faith-Hope, Watson pointed out that the nurse must instill in

the other person a sense of faith and hope about the treatment and the

nurse’s competence (Fawcett, 2000).

Watson noted the development of sensitivity to self and others, which

is the focus of the third carative factor, Being Sensitive to Self and

Others, plays a part in the nurse’s development of self, the ability to utilize

the self with others, and the ability to give holistic care. The fourth carative

factor, Developing a Helping-Trusting, Caring Relationship, is

accomplished when the nurse views the other person as a separate thinking

and feeling being. Watson maintained the attitudinal processes of

congruence, or genuineness, empathy, and nonpossessive warmth are

essential elements of the helping-trusting relationship. She further

maintained that a helping-trusting relationship is a basic element of high-

quality nursing care (Fawcett, 2000).

The fifth carative factor, Promoting and Accepting the Expression

of Positive and Negative Feelings and Emotions, points to the range of

feelings and emotions experienced by both nurse and other(s) and the need

to facilitate the expression of such feelings and emotions. Watson stated the

sixth carative factor, Engaging in Creative, Individualized Problem-

Solving Caring Processes, focuses attention on the “full use of self and all

domains of knowledge, including empirical, aesthetic, intuitive, affective, and

ethical knowledge.” (Fawcett, 2000).

The seventh carative factor, Promoting Transpersonal Teaching-

Learning, emphasizes Watson’s view that nurses and patients are

coparticipants in the process of learning. Watson linked the eight carative

factor, Attending to Supportive, Protective, or Corrective mental,

Physical, Societal, and Spiritual Environments, with the quality of

holistic health care (Fawcett, 2000).

The ninth carative factor, Assisting with Gratification of Basic

Human Needs while Preserving Human Dignity and Wholeness,

Watson identified and hierarchically ordered the needs she regarded as most

relevant to nursing as human caring. The tenth carative factor, Allowing

For, and Being Open To, Existential-Phenomenological-Spiritual

Dimensions of Caring and Healing That Cannot Be Fully Explained

Scientifically Through Modern Western Medicine, emphasizes the

importance of appreciating and understanding the inner world of each

person and the meaning each one finds in life, as well as helping others to

find meaning in life. “Dealing with another person as he or she is and in

relation to what he or she would like to be or could be is”, according to

Watson, “a matter of existential-phenomenological [and spiritual] concern for

the nurse who practices the science of [human] caring.” Watson’s addition of

the phrase “that cannot be fully explained scientifically through modern

Western medicine” to this carative factor implies that she recognizes the

possibility of phenomena that are more in keeping with nonempirical ways of

knowing. (Fawcett, 2000).

While some of the basic tenets of the original carative factors still hold, and

indeed are used as the basis for some theory-guided practice models and

research, what I am proposing here, as part of my evolution and evolution of

these ideas and the theory itself, is to transpose the "carative factors" into

"clinical caritas processes". For example, consider the following within the

context of clinical caritas, and emerging, transpersonal caring theory (Parker,

2002).

From Carative Factors To Clinical Caritas Processes

As carative factors evolve within an expanding perspective, as my ideas and

values evolve, I now offer the following translation of the original carative

factors into clinical caritas processes, suggesting more open ways in which

they can be considered. For example (Parker, 2002),

1. Formation of humanistic-altruistic system of values becomes: "Practice of

loving-kindness and equanimity within context of caring consciousness";

2. Instillation of faith-hope, becomes: "Being authentically present, and

enabling and sustaining the deep belief system and subjective life world of

self and one-being-cared- for";

3. Cultivation of sensitivity to one’s self and to others becomes: "Cultivation

of one’s own spiritual practices and transpersonal self, going beyond ego

self";

4. Development of a helping-trusting, human caring relationship becomes:

"Developing and sustaining a helping-trusting, authentic caring relationship";

5. Promotion and acceptance of the expression of positive and negative

feelings, becomes: "Being present to, and supportive of the expression of

positive and negative feelings as a connection with deeper spirit of self and

the one-being-cared-for";

6. Systematic use of a creative problem-solving caring process becomes:

"creative use of self and all ways of knowing as part of the caring process; to

engage in artistry of caring-healing practices";

7. Promotion of transpersonal teaching-learning becomes: "Engaging in

genuine teaching-learning experience that attends to unity of being and

meaning attempting to stay within other’s frame of reference";

8. Provision for a supportive, protective, and/or corrective mental, physical,

societal, and spiritual environment, becomes: "Creating healing environment

at all levels, (physical as well as non-physical, subtle environment of energy

and consciousness, whereby wholeness, beauty, comfort, dignity, and peace

are potentiated";

9. Assistance with gratification of human needs becomes: "assisting with

basic needs, with an intentional caring consciousness, administering ‘human

care essentials’, which potentiate alignment of mindbodyspirit, wholeness,

and unity of being in all aspects of care"; tending to both embodied spirit and

evolving spiritual emergence;

10. Allowance for existential-phenomenological-spiritual forces becomes:

"opening and attending to spiritual-mysterious, and existential dimensions of

one’s own life-death; soul care for self and the one-being-care-for."

What differs in the Clinical Caritas framework is that a decidedly

spiritual dimension and an overt evocation of love and caring merge into a

new paradigm for the next millennium. Such a perspective ironically places

nursing within its most mature framework, consistent with the Nightingale

model of nursing, yet to be actualized, but awaiting its evolution within a

caring-healing theory. This direction ironically while embedded in theory,

goes beyond theory and becomes a converging paradigm for nursing’s future

(Parker, 2002).

Thus, Watson considers her work more a philosophical, ethical,

intellectual blueprint for nursing’s evolving disciplinary/professional matrix,

rather than a specific theory per sé. Nevertheless, others interact with the

original work at levels of concreteness or abstractness; the caring theory has

been, and is being used, as a guide for educational curricula, clinical practice

models, methods for research and inquiry, as well as administrative

directions for nursing and health care delivery (Parker, 2002).

This work posits a value’s explicit moral foundation and takes a specific

position with respect to the centrality of human caring, "caritas" and love as

now an ethic and ontology, as well as a critical starting point for nursing's

existence, broad societal mission, and the basis for further advancement for

caring-healing practices. Nevertheless, it’s use and evolution are dependent

upon "critical, reflective practices that must be continuously questioned and

critiqued in order to remain dynamic, flexible, and endlessly self-revising and

emergent" (Watson, Blueprint; 1996, p. 143) (Parker, 2002).

Ironically, this work is congruent with recent reports on health care and

health professional educational reform, which call for "centrality of

caringhealing relationships" as the foundation for all health professional

education and practice reform. I quote (Parker, 2002):

The central task of health professions education - in

nursing, medicine, dentistry, public health, psychology, social

work, and the allied health professions - must be to help

students, faculty, and practitioners learn how to form caring,

healing relationships with patients, and their communities, and

with each other, and with themselves…the knowledge, skills, and

values necessary for effective relationships… Developing

practitioners mature as reflective learners and professionals who

understand the patient as a person, recognize and deal with

multiple contributions to health and illness, and understand the

essential nature of healing relationships. (Pew-Fetzer Task Force

Report, 1994, p. 39)

Transpersonal Caring Relationship

Watson termed transpersonal and a transpersonal caring relationship

as the foundation of the work; transpersonal conveys a concern for the inner

life world and subjective meaning of another who is fully embodied, but

transpersonal also goes beyond the ego self and beyond the given moment,

reaching to the deeper connections to spirit and with the broader universe.

Transpersonal caring seeks to connect with and embrace the spirit or soul of

others through the processes of caring and healing and being in authentic

relation, in the moment (Parker, 2002).

According to Watson, such a transpersonal relation is influenced by the

caring consciousness and intentionality of the nurse as she or he enters into

the life space or phenomenal field of another person, and is able to detect

the other person’s condition of being (at the soul, spirit level). It implies a

focus on the uniqueness of self and other and the uniqueness of the

moment, wherein the coming together is mutual and reciprocal, each fully

embodied in the moment, while paradoxically capable of transcending the

moment, open to new possibilities (Parker, 2002).

Transpersonal caring calls for an authenticity of being and becoming,

an ability to be present to self and other in a reflective frame; the

transpersonal nurse has the ability to center consciousness and intentionality

on caring, healing, and wholeness, rather than on disease, illness and

pathology. Watson stated within the model of transpersonal caring, clinical

caritas consciousness is engaged at a foundational ethical level for entry into

this framework. The nurse attempts to enter into and stay within the other’s

frame of reference for connecting with the inner life world of meaning and

spirit of the other; together they join in a mutual search for meaning and

wholeness of being and becoming to potentiate comfort measures, pain

control, a sense of well-being, wholeness, or even spiritual transcendence of

suffering. The person is viewed as whole and complete, regardless of illness

or disease (Parker, 2002).

Nursing’s goal is to help persons gain a higher degree of harmony

within the mindbodyspirit, which generates self-knowledge, self reverence,

self-healing, and self-care processes while allowing for diversity and

possibility. In ontology of relation, the nurse pursues this goal through

transpersonal caring relationship and the human care process and responds

to person’s subjective worlds in such a way that individuals can find meaning

in their existence through exploring the meaning of their disharmony,

suffering, and turmoil within the lived experience. This exploration promotes

self-knowledge, self-control, self-love, choice based on subjective intent, and

self-determination (Tomey, 2002).

The concept TRANSPERSONAL CARING RELATIONSHIP encompasses three

dimensions – self, phenomenal field and intersubjectivity.

Self

Watson identified the self as a transpersonal mind body spirit oneness,

an embodied spirit. The self encompasses the self as it is, the ideal self that

the person would like to be, the ego self, and the spiritual self, which is

synonymous with the geist or soul or essence of the person, and which is the

highest sense of self (Fawcett, 2000).

Phenomenal Field

The phenomenal field is the totality of human experience (one’s being

in the world). The individual frame of reference that can be known only to

the person (Fawcett, 2000).

Intersubjective

Transpersonal refers to an intersubjective human-to-human

relationship in which the person of the nurse affects and is affected by the

person of the other. They share a phenomenal filed which becomes part of

the life history of both and are coparticipants in becoming in the now and the

future. Watson said that the intersubjectivity human flow from one to the

other (is such that it) has the potential to allow the care giver to become the

care receiver (Fawcett, 2000).

The three dimensions of the concept TRANPSERSONAL CARING

RELATIONSHIP –Self, Phenomenal Field, and Intersubjectivity-are regarded as

integral. Watson explained:

Human care can begin when the nurse enters into the life space or

phenomenal field of another person, is able to detect the other

person’s condition of being (spirit, soul), feels this condition in such a

way that the recipient has a release of subjective feelings and thoughts

he or she had been longing to release. As such, there is an

intersubjective flow between the nurse and patient (Fawcett, 2000).

Assumptions of Transpersonal Caring Relationship

Moral commitment, intentionality and caritas consciousness by the nurse

protects, enhances and potentiates human dignity, wholeness and healing

whereby allowing a person to create or co-create his/her own meaning for

existence. The conscious will of the nurse affirms the subjective and spiritual

significance of the patient while seeking to sustain caring in the midst of

threat and despair, biological, institutional or otherwise. The result is an

honoring of an I-Thou Relationship rather than an I-It Relationship (Parker,

2002).

The nurse seeks to recognize, accurately detect, and connect with the

inner condition of spirit of another through genuine presencing and being

centered in the caring moment; actions, words, behaviors, cognition, body

language, feelings, intuition, thought, senses, the energy field, and so on, all

contribute to transpersonal caring connection. The nurse’s ability to connect

with another at this transpersonal spirit- to- spirit level is translated via

movements, gestures, facial expressions, procedures, information, touch,

sound, verbal expressions and other scientific, technical, aesthetic, and

human means of communication, into nursing human art/acts or intentional

caring-healing modalities (Parker, 2002).

The caring-healing modalities within the context of transpersonal

caring/caritas consciousness potentiate harmony, wholeness, unity of being

by releasing some of the disharmony, the blocked energy that interferes with

the natural healing processes; thus the nurse helps another through this

process to access the healer within, in the fullest sense of Nightingale’s view

of nursing (Parker, 2002).

On-going personal and professional development and spiritual growth,

and personal spiritual practice assist the nurse in entering into this deeper

level of professional healing practice, allowing for awakening to a

transpersonal condition of world and more fully actualizing the "ontological

competencies" necessary for this level of advanced practice of nursing. The

nurse’s own life history, previous experiences, opportunities for focused

studies, having lived through or experienced various human conditions, or of

having imagined others’ feelings in various circumstances, are valuable

teachers for this work; to some degree the necessary knowledge and

consciousness can be gained through work with other cultures, study of the

humanities (art, drama, literature, personal story, narratives of illness

journeys, etc.) along with an exploration of one’s own values, deep beliefs,

and relationship with self, others, and one’s world. Other facilitators are

personal growth experiences such as psychotherapy, transpersonal

psychology, meditation, bio-energetics work, and other models for spiritual

awakening. Continuous growth is on-going for developing and maturing

within a transpersonal caring model. The notion of health professionals as

wounded healers is acknowledged as part of the necessary growth and

compassion called forth within this theory/philosophy (Parker, 2002).

Caring Moment/ Caring Occasion

A caring occasion occurs whenever the nurse and another come together

with their unique life histories and phenomenal fields in a human-to-human

transaction. The coming together in a given moment becomes a focal point

in space and time. It becomes transcendent whereby experience and

perception take place, but the actual caring occasion has a greater field of its

own in a given moment. The process goes beyond itself, yet arises from

aspects of itself that become part of the life history of each person, as well

as part of some larger, more complex pattern of life. (Watson, 1985/1988, p.

59; 1996 p.157 reprinted (Parker, 2002)).

A caring moment involves an action and choice by both the nurse and

the other. The moment of coming together presents them with the

opportunity to decide how to be in the moment and in the relationship as

where as what to do with and during the moment. If the caring moment is

transpersonal, each feels a connection with the other at the spirit level, thus

it transcends time and space, opening up new possibilities for healing and

human connection at a deeper level than physical interaction. For example

(Parker, 2002):

….We learn from one another how to be human by identifying

ourselves with others, finding their dilemmas in ourselves. What

we all learn from it is self-knowledge. The self we learn about …is

every self. IT is universal – the human self. We learn to recognize

ourselves in others…(it) keeps alive our common humanity and

avoids reducing self or other to the moral status of object.

(Watson, 1985/1988, pp. 59-60).

Caring (Healing) Consciousness

The dynamic of transpersonal caring (healing) within a caring moment is

manifest in a field of consciousness. The transpersonal dimensions of a

caring moment are affected by the nurse’s consciousness in the caring

moment, which in turn affects the field of the whole. The role of

consciousness with respect to a holographic view of science have been

discussed in earlier writings (Watson, 1992, p. 148) and include the following

points (Parker, 2002):

• The whole caring-healing-loving consciousness is contained within a

single caring moment.

• The one caring and the one being cared for are interconnected; the

caring-healing process is connected with the other human(s) and the

higher energy of the universe;

• The caring-healing-loving consciousness of the nurse is communicated

to the one being cared for;

• Caring-healing-loving consciousness exists through and transcends

time and space and can be dominant over physical dimensions.

Within this context, it is acknowledged that the process is relational

and connected; it transcends time, space, and physicality. The process is

intersubjective with transcendent possibilities that go beyond the given

caring moment (Parker, 2002).

Implications of the Caring Model

The caring model or theory can also be considered a philosophical and

moral/ethical foundation for professional nursing and part of the central

focus for nursing at the disciplinary level. A model of caring includes a call

for both art and science; it offers a framework that embraces and intersects

with art, science, humanities, spirituality, and new dimensions of

mindbodyspirit medicine and nursing evolving openly as central to human

phenomena of nursing practice (Parker, 2002).

Watson emphasized that it is possible to read, study, learn about, even

teach and research the caring theory; however, to truly "get it," one has to

personally experience it; thus the model is both an invitation and an

opportunity to interact with the ideas, experiment with and grow within the

philosophy, and living it out in one’s personal/professional life (Parker, 2002).

The ideas as originally developed, as well as in the current evolving

phase (see Watson, 1999), provide others a chance to assess, critique and

see where or how, or if, one may locate self within the framework or the

emerging ideas in relation to their own "theories and philosophies of

professional nursing and/or caring practice." If one chooses to use the caring

perspective as theory, model, philosophy, ethic or ethos for transforming self

and practice, or self and system, the following questions may help (Watson,

1996, p. 161) (Parker, 2002):

Is there congruence between (a) the values and major concepts and

beliefs in the model and the given nurse, group, system, organization,

curriculum, population needs, clinical administrative setting, or other

entity that is considering interacting with the caring model to

transform and/or improve practice?

What is one’s view of human? And what it means to be human, caring,

healing, becoming, growing, transforming, etc. For example: In words

of Teilhard de Chardin: "Are we humans having a bspiritual experience,

or are we spiritual being having a human experience?" Such thinking in

regard to this philosophical question can guide one’s worldview and

help to clarify where one may locate self within the caring framework.

Are those interacting and engaging in the model interested in their

own personal evolution? Are they committed to seeking authentic

connections and caring-healing relationships with self and others?

Are those involved "conscious" of their caring-caritas or non-caring

consciousness and intentionally in a given moment and at an individual

and system level? Are they interested and committed to expanding

their caring consciousness and actions to self, other, environment,

nature and wider universe?

Are those working within the model interested in shifting their focus

from a modern medical science-technocure orientation to a true

caring-healing-loving model?

This work, in both its original and evolving forms, seeks to develop

caring as an ontological and theoretical-philosophical-ethical framework for

the profession and discipline of nursing and clarify its mature relationship

and distinct intersection with other health sciences. Nursing caring theory

based activities as guides to practice, education and research have

developed throughout the USA and other parts of the world. Watson’s work is

consistently one of the nursing caring theories used as a guide. Nurses’

reflective-critical practice models are increasingly adhering to caring ethic

and ethos (Parker, 2002).

Because the nature of the use of the caring theory is fluid, dynamic,

and undergoing constant change in various settings around the world and

locally I am not able to offer updated summaries of activities. Earlier

publications seek to provide examples of how the work is used, or has been

used in specific settings (Parker, 2002).

III. THEORY SYNTHESIS

CLINICAL APPLICATION

The intent of this section is to create a better understanding of Watson’s

theory through a clinical story. For this reason, whenever a single or several

clinical caritas process(es) (CCP) are encountered, their appropriate numbers

are identified within parentheses. The reader shall also notice that this story

deviates from the traditional format as it includes reflection and analysis, the

purpose of which is to provide an expeditious grasp related to these abstract

concepts. Additionally, the reader can also refer to Table 3 for an example of

a caring process using Watson’s caring theory (adapted from Cara, 1999;

Cara & Gagnon, 2000).

It is December 5th, I am assigned to take care of Mr. Smith, a 55-year-old

Caucasian man who will undergo his 5th amputation. Gangrene has ravaged

both feet and legs. He is scheduled for an above knee amputation of his right

leg, because the last amputation did not heal properly. I know him quite well,

since I took care of him during his past hospitalizations (CCP#4). I’ve always

liked this patient (CCP#1), it seems that we connected right away after our

first meeting (CCP#4). He shared with me his life story [referred to as

phenomenal field by Watson], which allowed me to know him as a person not

just “a case” going for surgery on our unit.

I welcome him as he is admitted onto the unit. As we glance to each other,

he returns a faint smile. [At this moment, a caring occasion takes place.] I

ask him how he is doing and tell him that since our last meeting I thought of

some creative ways of how he could remember to take his medicine (CCP#6,

CCP#7). [According to Watson, the nurse’s creativity contributes to making

nursing an art.] He responds that he will be happy to discuss it and also asks

how I have been doing. Mr. Smith knows me as a person, he does not

consider me as just another nurse, I am “his nurse.” He knows that I care for

him and that I am committed to helping him through his ordeal (CCP#4).

[This is an example of what Watson means by our relationship becoming part

of both our life history.]

From his faint smile I can sense that he is depressed. Probably since part of

his leg has to be amputated some more. However, I cannot make this

assumption and will have to discuss his perceptions and feelings pertaining

to his lived experience (CCP#3, CCP#5, CCP#10). While I help him settle in

his room, I arrange his environment so that he can feel at ease (CCP#8).

Right away, I use the time we have together to ask about himself, his

feelings, and his priorities for his care plan and hospitalization (CCP#5,

CCP#10). He explains that he wants to be home for Christmas because his

son and grandson are coming to visit. Consequently, we will have to plan

everything according to his priority. [Although caring takes “too much time”

according to some people, I have found, through experience, that focusing

on the patients’ priorities and meaning will often help them participate more

actively in their healing process. Therefore, even though more time was

taken initially, I noticed that, eventually, more time is saved in caring for

patients. As Watson (2000) emphasizes, the outcomes that may arise,

develop from the process and are characterized and guided by the inner

journey of the one being cared-for, not the one caring (or attempting to

cure).]

While I help him settle in his bed, he asks for the bedpan (CCP#9). As I install

the bedpan delicately underneath him, he says to me, “Look at me, I can’t

even manage by myself anymore! I feel like a piece of meat in this bed! Will

this surgery work this time or is it a waste of time and money?” I am troubled

by his comment and ask him to clarify (CCP#5). He says that people used to

respect him but losing his legs also made him lose this respect. I am

speechless! [My patient makes me realize the importance of Watson’s caring

values based on respecting and preserving human dignity. Yet, hearing how

other people’s reaction affects him, I understand more than ever that Mr.

Smith and his environment are interrelated (CCP#8, CCP#10)]. He continues

to say, “If only you knew me back then, when I was walking and working.

Without my legs, I am no longer the same guy!” I ask how losing his legs

made him different (CCP#5, CCP#9, CCP#10). He says that he no longer has

social recognition and usefulness. [I find it difficult to consider how people

can disrespect a human being for being different! Yet, one has to look

beyond the body, and look at the mind and the soul.] Sensing that he wants

to be alone, I tell him that I will return in a few minutes and I gently pull the

curtains to provide privacy and comfort (CCP#8). Trusting that I will return,

he thanks me for my help (CCP#4). As I leave the room, I feel powerless

towards my patient, not knowing what to say or what to do. [Watson (2000)

reminds us that being caring is being vulnerable. “If we are not able to be

vulnerable with ourselves and others, we become robotic, mechanical,

detached and de-personal in our lives and work and relationships” (p. 6). I

want to help him reach some harmony (mindbodyspirit) in his life again

(CCP#9). Promoting hope to patients when their situation is somber can be

quite overwhelming (CCP#2). But since I believe that giving hope is essential

to his harmony, I will have to be somewhat creative (CCP#6). Caring for him

is important to me, it is my motivation that contributes to the way I actualize

myself professionally. Caring allows me to work with passion! It becomes

clear that my most important goal is establishing a transpersonal caring

relationship that will, as Watson states, “protect, enhance, and preserve my

patient’s dignity, humanity, wholeness, and inner harmony.” Caring, for me,

is what nursing is all about!] (C.C., RN)

(http://www.humancaring.org/conted/Pragmatic%20View.pdf)

JEAN WATSON’S THEORY OF CARING IN NURSING EDUCATION

The past decade has been rich in the advancement of complementary

approaches to traditional medicine. Medical science has confirmed the

benefits of stress reduction techniques such as yoga, meditation and qi-

gong. Another technique that is increasingly incorporated into the

conventional practice of medicine is that of mindfulness training. One

mindfulness practitioner is Jean Watson, who promotes a theory of caring as

the central tenet in her teaching philosophy.

Framework

Jean Watson's theory of caring focuses on love as the primary healing tool in

nursing. Watson advocates a mental state of caring, focused not on the self

but, rather, on the patient. Watson believes that in an ego-less state, a nurse

intuitively knows the needs of the patient. This methodology is not new; her

focus fits well within the scope of Betty Neumann's theory of nursing, whose

seminal work in the mid 20th century outlined the idea of the role of the

nurse as an integral tool in creating balance, not only in the physical body

but in the patient's emotional state as well.

Energy Awareness

Because nurses are on the front lines of caring, Watson believes that nurses

should be acutely aware of the type of energy, whether caring or

indifference, they exude. According to Watson, there is evidence that a

loving approach creates a physical change in the environment, thereby

creating a healing energy for those who come in contact with it.

Nursing Theory in Practice

Nursing theory in practice is a fourfold process which comprises overall

education, skill practice, practical application of existing theory, and

examination and integration of new theories including psychological and

philosophical discoveries.

Jean Watson addresses these aspects of nursing theory in her nurse training

program at the University of Colorado's Denver Health Sciences Center.

Additionally, Watson's own Center for Human Caring promotes her caring

philosophy in several forms including multi-continent training sessions, web-

seminar educational materials, spiritually-centering meditation and

devotional media, and an annual professional retreat to discuss practical

nursing as well as application of new psychological theories.

Influences

Jean Watson has been highly influenced by the author Eckhart Tolle, whose

work focuses on the benefits of love-centered living. Tolle's writing explores

the idea that the human race is currently involved in a shift of

consciousness, through the realization that the self is already whole in the

present moment.

Jean Watson is also a proponent of the work of the HeartMath Institute, a

research center directed by physicians, which focuses on recent medical

evidence that our emotions significantly affect our health and well being.

HeartMath's philosophy is based on the idea that hormones secreted when

we are under stress cause inflammation and, ultimately, disease, while

hormones secreted when we are at peace are healing to the body. The

HeartMath Institute provides guided meditations as well as centering

exercises designed to stop stressful emotions by replacing negative thoughts

with helpful ones.

Million Nurse Project

Jean Watson's Million Nurse Global Caring Field Meditation, held on January 1,

2010, initiated a worldwide day of caring, where nurses across the world

shared in love-centered consciousness towards one another and their

patients. (http://connected.waldenu.edu/curriculum-resources/learning-

centers/item/860-jean-watsons-theory-of-caring-nursing-education)

IV. THEORY DERIVIATION

“Too often we underestimate the power of a touch, a smile, a kind word, a

listening ear, an honest compliment, or the smallest act of caring, all of

which have the potential to turn a life around.”

Leo F. Buscaglia

We always tend to forget that

big things come in small

packages. Small efforts we

make everyday might not be a

big deal for us but it might be a

big deal for others; just as

incorporating nursing with love

and care. When nurses apply

their profession with a little

love and care, this would result

in the holistic healing of an ill person. Watson stated in her theory that we

should not view a person as separate being but rather a unified being. We

should consider a person’s mindbodyspirit when giving care to them.

Nursing is just like seeing and treating one patient as your own child.

As a mother, she gives love and care to her children. It is very important that

we show our care and our love to our patients. Nursing is not just the mere

fact of giving medications and positioning the patient. It is viewing the

patient as a whole. Nurses should not only look after the physical illness

inflicted in a person, but also they should go deeper with the interaction of a

patient. Every person is like a circle. They should be viewed as a whole. It is

when we see the person as a whole being that we give our patients the

chance to have a holistic wellness.

V. BIBLIOGRAPHY

BOOKS

Alligod, M. R. and Tomey, A. M. (2002). Nursing Theory: Utilization and

Application. 2nd ed. St. Louis: Mosby.

Arnold, E. and Underman-Boggs, K. (1989). Interpersonal Relationships:

Professional Communication Skills for Nurses. 4th ed. U.S.A.: Elsevier

Science.

Fawcett, J. (2000). Analysis and Evaluation of Contemporary Nursing

Knowledge: Nursing Models and Theories. Philadelphia: F.A. Davis.

George, J. (2008). Nursing Theories: The Base for Professional Nursing

Practice. 5th ed. New Jersey: Prentice Hall.

Parker, M. (2002). Nursing Theories and Nursing Practice. Philadelphia: F.A.

Davis.

Tomey, A. (1994). Nursing theorist and their work. 5th ed. St. Louis, Missouri:

Mosby year book.

INTERNET SOURCES

http://connected.waldenu.edu/curriculum-resources/learning-centers/item/

860-jean-watsons-theory-of-caring-nursing-education

http://www.humancaring.org/conted/Pragmatic%20View.pdf

http://www.humancaring.org/conted/Pragmatic%20View.pdf

http://www.watsoncaringscience.org/cfwebstorefb/index.cfm/feature/84/

theory-of-human-caring.cfm

http://www.watsoncaringscience.org/j_watson/theory.html